Healthcare Provider Details

I. General information

NPI: 1578950457
Provider Name (Legal Business Name): NICOLE ASHLEY SMITH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2015
Last Update Date: 04/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 PORTLAND RD
SACO ME
04072-9673
US

IV. Provider business mailing address

150B BROADTURN RD
SCARBOROUGH ME
04074-9600
US

V. Phone/Fax

Practice location:
  • Phone: 207-439-5104
  • Fax:
Mailing address:
  • Phone: 978-424-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOA3005
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: